Safety events in pediatric out-of-hospital cardiac arrest

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9 Scopus citations


Objective: The objective of this study was to explore the types of patient safety events that take place during pediatric out-of-hospital cardiac arrest resuscitation. Methods: Retrospective medical record review from a single large urban EMS system of EMS-treated pediatric (< 18 years of age) out-of-hospital cardiac arrests (OHCA) occurring between 2008 and 2011. A chart review tool was developed for this project and each chart was reviewed by a multidisciplinary review panel. Safety events were identified in the following clinical domains: resuscitation; assessment, impression/diagnosis, and clinical decision making; airway/breathing; fluids and medications; procedures; equipment; environment; and system. Results: From a total of 497 critical transports during the study period, we identified 35 OHCA cases (7%). A total of 87% of OHCA cases had a safety event identified. Epinephrine overdoses were identified in 31% of the OHCA cases, most of which were 10-fold overdoses. Other medication errors included failure to administer epinephrine when indicated and administration of atropine when not indicated. In 20% of OHCA cases, 3 or more intubation attempts took place or intubation attempts were ultimately not successful. Lack of end-tidal C02 use for tube confirmation was also common. The most common arrest algorithm errors were placing an advanced airway too early (before administration of epinephrine) and giving a medication not included in the algorithm, primarily atropine, both occurring in almost 1/3 of cases. Conclusions: Safety events were common during pediatric OHCA resuscitation especially in the domains of medications, airway/breathing, and arrest algorithms.

Original languageEnglish (US)
Pages (from-to)380-383
Number of pages4
JournalAmerican Journal of Emergency Medicine
Issue number3
StatePublished - Mar 2018


  • Emergency medical services
  • Heart arrest
  • Pediatrics

ASJC Scopus subject areas

  • Emergency Medicine


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